M.S. Program in Clinical-Counseling Psychology

Preregistration Practicum Approval Form

(This form must be completed one month prior to the end of the semester prior to practicum and submitted to the Program Coordinator)

Student’s name:______________________________

VSU Faculty Supervisor (Practicum course instructor):___________________________

VSU Advisor:______________________________

Student’s Phone: Home:_____________________Work:_______________________

Student’s email address:__________________________________________

Semester of Practicum: term:________ year:________

Has the practicum site been previously approved?   YES   NO

Practicum Site name:__________________________________________

Site Address:___________________________________________________________

On-Site Supervisor: _______________________Phone: (____)_________________

Qualifications of Supervisor (degree, license):__________________________________

Type of Clientele (incl. age range):___________________________________________

Activities Available (e.g., type of testing, group/ind. couns.): ______________________

________________________________________________________________________

Type of liability insurance (attach photocopy):_______________________

Term Prepracticum was completed with grade of B or better: term:________ year:________

Term Comprehensive Exams were successfully completed: term:________ year:________

_____________________________________ ____________________________________

Signature of Student

Signature of Advisor